Screening and treatment of sexually transmitted disease is essential to the clinical repertoire of all physicians who care for adolescents.
Any doctor who provides primary health care to teens – whether trained as a pediatrician, family physician, obstetrician-gynecologist, or internist – should assume the responsibility of STD screening and counseling of all adolescent patients as part of anticipatory guidance, along with treatment if necessary.
Dr. Bonnie Word
Recommendations for routine counseling and screening of sexually active adolescents for specific STDs have been made over the last few years by various government agency and professional organizations, but have only now been included in the "Sexually Transmitted Diseases Treatment Guidelines, 2010" published in December by the Centers for Disease Control and Prevention (MMWR 2010;59:[RR-12]).
Of the 11 identified updates in the guidelines (last published in 2006), I would like to focus on those affecting the adolescent. Prevalence of several STDs is highest among this group. Specifically, rates of chlamydia and gonorrhea are highest among females aged 15-19 years, according to the CDC report. Adolescence is also the time when many are first exposed to human papillomavirus virus (HPV).
Why are adolescents at such a high risk for STDs? Risk increases when sexual activity is initiated at a young age, when injected drug use is present, and if male, the sexual encounters are with another male. Additional contributing factors include multiple sexual partners, sequential partners of brief duration (serially monogamous), inconsistent and/or inappropriate use of barrier methods, and challenges to accessing health care.
According to the new CDC STD guidelines, routine screening of Chlamydia trachomatis is recommended annually for all sexually active females aged 25 years and younger. While routine chlamydia screening is not recommended for sexually active young men – based on feasibility, efficacy, and cost-effectiveness – such screening should be considered in high-risk clinical settings such as adolescent clinics, correctional facilities, and STD clinics.
This recommendation, originally from the U.S. Preventive Services Task Force (USPSTF), was published in an internal medicine journal where many pediatricians were not likely to have seen it (Ann. Intern. Med. 2007;147:128-34).
Similarly, routine screening for Neisseria gonorrhoeae also is recommended for all sexually active women less than 25 years of age, the group at greatest risk for the infection. The screening recommendation – also originally from the USPSTF – also applies to women with other risk factors including a previous gonorrhea infection, the presence of other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use.
Screening for HIV is not routinely advised, but it should be discussed with all adolescents and encouraged for those who are sexually active and those who use injection drugs. It is also recommended for all diagnosed with an STD.
Routine screening of adolescents who are asymptomatic for certain STDs – such as syphilis, trichomoniasis, bacterial vaginosis, herpes simplex virus, and hepatitis B virus – is not recommended. However, young males who have sex with males and pregnant adolescent females might require more thorough evaluation, according to the current CDC recommendations.
It might make us uncomfortable to think about, but our patients are growing up and are not immune to any of these high-risk situations. We have to be prepared to assist them as they transition from childhood to adolescence and ultimately adulthood.
Screening and counseling for sexual activity, STDs, and pregnancy prevention is just one of the quality measures now recommended to assess health services for adolescents. Many adolescents report that they do not have the opportunity to speak privately with their care provider. Confidentiality is paramount to any discussion, which also should be developmentally appropriate.
Health care providers additionally must feel comfortable obtaining and discussing their patients’ sexual history, while at the same time being culturally sensitive and nonjudgmental. They also should be knowledgeable about risky behavior interventions and treatments. All states and the District of Columbia allow adolescents to seek treatment for a presumed STD without parental consent.
But a recent study illustrates why testing must accompany those discussions. Of 14,012 young adults (mean age 21.9 years) who had been interviewed and screened three times beginning in adolescence as part of the National Longitudinal Study of Adolescent Health, 964 tested positive for C. trachomatis, N. gonorrhoeae, and/or Trichomonas vaginalis. Of those, 10.5% reported having abstained from sexual activity during the prior 12 months and, of those, nearly half (5.9% of the total) said they had never had penile/vaginal intercourse in their lives (Pediatrics 2011 Jan. 3 [doi: 10.1542/peds.2009-0892]).
The researchers found no correlation with any sociodemographic factor including age, gender, educational level, or race for discrepancies between STD test results and self-reports among the STD-positive participants. This is the first study that attempts to correlate responses to objective findings.